Module8

NeurologicalSystem

BasicAnatomyofNervousSystem

Nervoussystemconsistsof: CNS(CentralNervousSystem) PNS(PeripheralNervousSystem) ANS(AutonomicNervousSystem)

1.1 1.1.1

CNS(CentralNervousSystem) Brain

CNSconsistsofBrainandSpinalCord

BrainisVERYdelicateandisprotectby3meninges(membranes) Piamater(Innermostlayer) o Thinvascularmembrane Arachnoidmater(middlelayer) o Delicate/transparentmembrane Duramater(outermostlayer) o Touchfibrouslining CSFcushionoffluidstrawcolouredfluidhighglucosecontent Skullbones Brainmadeupofthreeparts: o Cerebrum o Cerebellum o BrainStem

1.1.1.1 Cerebrum
Cerebrumlargestpartofthebrain Dividedintoleftandrighthemisphere Eachhemisphereconsistsof: o Afrontallobe o Aparietallobe o Atemporallobe o Anoccipitallobe Memory,intelligence,senseofresponsibility,thinking,reasoning,moralsenseandhigherlearning Perceptionofpain,temperature,touchandspecialsenses:sight,hearing,tasteandsmell Initiationandcontrolofvoluntarymovements Cerebellumsmallermassofbraintissue Liesbeneathandbehindcerebrum Consistsof2hemispheresleftandright Mainfunctionistosmoothandcoordinatebodymovement Allowspersontowrite,rideabicycle,run,playsport Brainstemliesbetweencerebrumandspinalcord Dividedinto3sections o Midbrain o Pons o Medullaoblongata(controlsHRandRR) Controlsvitalbodilyfunctionse.g.cardiacandrespiratory,certainreflexese.g.coughingandvomiting

1.1.1.2 Cerebellum

1.1.1.3 BrainStem

1/17

Module8 1.1.2

NeurologicalSystem

SpinalCord
Spinalcordcontinuouswithmedullaoblongata Leavetheskullthroughforamenmagnumandextendsfromatlas(firstcervicalvertebra)toupperborderof secondlumbervertebra(L2) Liesinvertebralcanalandprotectedbyvertebralcolumn

Threemembranessurroundcored(continuousfromthoseofthebrain) o Piamater(Innermostlayer) Thinvascularmembrane o Arachnoidmater(middlelayer) Delicate/transparentmembrane o Duramater(outermostlayer) Touchfibrouslining SubarachnoidspacecontainsCSF(CerebrospinalFluid)whichiscontinuouswiththeCSFsurroundingthebrain

1.2

PNS(PeripheralNervousSystem)
PNScomposedof o 31pairsofspinalnerves o 12pairsofcranialnerves o Theselinkthebodysperipheralnervestospinalcord Thepairsare: o 8pairscervicalnerves o 12pairsthoracicnerves o 5pairslumbarnerves o 5pairssacralnerves o 1paircoccygealnerves

AfferentNerves:Nervefibresthatconductsensoryimpulsesfromskinandotherorganstospinalcord EfferentNerves:Nervefibresthatconductmotorimpulsesfromspinalcordtomuscles

2/17

Module8

NeurologicalSystem

Cranialnervesperformspecialfunctionsinheadandfacee.g.sight,smell,taste,hearingandfacialexpressions Threemajortypesofperipheralnerves: Sensorynerves o Carryinformationfrombodytobrainviaspinalcord Motornerves o CarrymovementcommandsfromCNStomuscles Connectingnerves o Onlyfoundinbrainandspinalcord o Connectssensoryandmotornerveswithshortfibres o Allowingcellsoneitherendtodirectlycommunicate CranialNerveNameFunction CNI CNII CNIII CNIV CNV CNVI CNVII CNVIII CNIX CNX CNXI CNXII Olfactory Optic Occulomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal Smell Vision Raiseeyelidsandfocus Movementofeyes Eyes&upperface,Upperjaw&face,Lowerjaw&scalp Movementofeyes Tasteanteriortongue,Musclesfacialexpressions Hearing&equilibrium Swallowing Speech,swallowing&autonomicfibres Impulsespharynx&larynx Movementoftongue

PNSalsoconsistsofANSwhichissubdividedintosympatheticandparasympatheticnervoussystemsandvoluntary nervoussystems

1.2.1

Physiologyofnervoussystem:

Nervoussystemcompriseoftwomainsections CNS(CentralNervousSystem) o Consistsofthebrainandspinalcord PNS(PeripheralNervousSystem) o Sensoryandmotornerves

1.3

ANSAutonomicNervousSystem
Regulatesfunctionsofthebodythatoccurwithoutconsciouseffort Involuntarysystem Controlfunctionsofmanyvitalorgans o Heart,lungs,bloodvessels,glandsandsmoothmuscles Composedof2parts o Sympatheticnervoussystem o Parasympatheticnervoussystem

3/17

Module8 1.3.1

NeurologicalSystem

Sympatheticnervoussystem

Sympatheticnervoussystemrespondstostress/emergencysituations o Fight/flight Inemergencysituations Adrenalglandisstimulatedtoproduceadrenaline(hormone) Adrenalinecausesincreaseinheartrateandbloodpressure(improvesbloodsupplytovitalorgansandmuscles) Constrictionofbloodvesselsofskin(limitsbleedingfromwoundsandshuntsbloodwhereneeded) Dilatespupils(letsmorelightin) Riseinbloodglucose(supplymoreenergy) Peristalsisdecreasesanddigestionslowsdown Usuallyaccompaniedbysweating/nauseaandvomiting

1.3.2

Parasympatheticnervoussystem

Parasympatheticnervoussystemmainlyconcernedwithvegetativefunction Digestion,bloodvesselsdilate,slowsheartrateandrelaxesmusclesofsphincters Oppositeeffecttosympatheticnervoussystem ParasympatheticnervoussystemandSympatheticnervoussystembalanceeachotheroutsobodysfunctionsremain stableandeffective. Sympathetic Parasympathetic Pupilsdilate Pupilsconstrict Rateincrease Ratedecrease Bronchidilaterateincrease Bronchiconstrict ratedecrease GastricjuicedecreasesDecreasefunction GastricjuiceincreasesIncreasefunction DecreasefunctionLossbladdercontrol Increasefunction Pale,cold,clammyskin Normalcolour&temperature Male:Ejaculation Male:Erection Bloodvesselsconstrict Bloodvesselsdilate Musclefunctionincrease Musclefunctiondecrease

1.4

VoluntaryNervousSystem

VoluntaryNervousSystemresponsibleforfunctionweDOhavecontrolovere.g.running,walking,usingourhandsand feet. Summary Nervoussystem:CNS+PNS CNS: BrainandSpinalcord PNS: Sensoryandmotornerves Autonomicandvoluntarysystems AutonomicNS: Sympatheticandparasympathetic VoluntaryNS: Controlledfunctions Sympathetic: Survivalfunctions Parasympathetic: Vegetativefunctions

4/17

Module8

NeurologicalSystem

2
2.1

ClinicalConditions
(CVA)CerebroVascularAccident
AlsoknownasstrokeorCVI(CerebroVascularIncident) o Termusedforsuddenvascularcatastrophe o Usuallyaclotorhaemorrhageinthebrain Resultsin: o Weakness,paralysis,speechdisorder,comaandconfusion Moststrokesoccurinelderlypeople

Cerebralbloodflowmaybeinterruptedby: Clottingand/obstructionofcerebralartery(thrombosis) Ruptureofcerebralartery(arterialruptureorhaemorrhage) Obstructionofcerebralarterybyclotformedsomewhereelsebuttransportedtothebrainincirculation (cerebralembolism)

5/17

Module8 2.1.1

NeurologicalSystem

Haemorrhagicstoke
Resultsfrombleedinginthebrain Arterialrupture Highbloodpressureisahighriskfactor Somepeoplearebornwithaneurysms

2.1.2

Ischaemicstoke
Resultwhenbloodflowtoparticularpartofthebrainiscutoffbyblockage(insidevessel) Thrombosis Clottingofcerebralarteries Cerebralembolism Blockagebyclotformedelsewhereinthebody

2.1.3

TAI(TransientIschemicAttack)
TIAisaministroke Strokesymptomsgoawaywithin24hours EveryTIAisanemergency TIAmaybewarningofalargerstroke Pt.withpossibleTIAshouldbeevaluatedbyphysician

2.1.3.1 Strokesmaycausethefollowingeffects
HemiplegiaParalysisofonesideofthebody Lefthemisphere o Aphasia Inabilitytospeak/understandspeech o Receptiveaphasia Abilitytospeakbutunabletounderstandspeech o Expressiveaphasia Inabilitytospeakcorrectlybutabletounderstandspeech Righthemisphere o Dysarthria Abletounderstandbuthardtobeunderstood o Diminishedconsciousness Rangingfromconfusiontocoma o Difficultyinspeechorvision o DilatedpupilonSAMEsideasCVA o Convulsions o Dyspneaanddifficultyinswallowing Excessivesalivationpt.maybedrooling o Slowpoundingpulse o Hypertension o Cheynestokes(respiration)

2.1.3.2 Strokesmimics(donotconfuse)
Hypoglycaemia PostictalState o Stateafterepilepticfit Subdural/epiduralbleeding

6/17

Module8 2.1.4

NeurologicalSystem

Managementofstrokept.
ABC Assessvitalsigns Administeroxygen(atleast60%) Observeforirregularbreathingpatterns(Cheynestokes) Suctioningmayberequired o Becarefulnottoinducevomiting Transportleftlateralorwithparalysedsidedown Constantreassurance

2.2

Convulsions
Usuallycausebyabnormalfocusofelectricalactivityinbrain Manycausesofconvulsions o Epilepsy o Highfeverinchildren o Hypoglycaemia o Hypoxia o Braininjury Convulsionmaybegeneralizedandaffectthewholebody Orpartialandaffectonlypartofthebody Bestknownconvulsionisusuallyduetograndmalepilepsy

2.2.1 Stageofepilepsy 2.2.1.1 Aura

Auraisbriefwarningthatseizureisabouttooccur Maytakeformofabnormalsmell Twitch,dizziness/strangefeeling

2.2.1.2 Tonic
Tonicphasesuddenlossofconsciousness Pt.fallstotheground Entirebodybecomestiffduetomusclespasm Pt.willbeunabletobreathe

2.2.1.3 Clonic
Clonicphaseseriesofmuscularcontractionsalternatingwithmuscularrelaxation(veryfastmovements) Duringthisphase,pt.maybitetheirtonguefromchampingjaw Frothysputumwillbeproducefromthisaction(sometimestingedwithblood) Pt.usuallyurinates Lackofbreathingcancausecyanosis

2.2.1.4 Postictal
PostictalphaseiswhenClonicphasestops Pt.remainsunconsciousfor1030min Whenawake,usuallydrunkandconfused Airwaymaybecomeobstructedbytongue/vomitus Alwaysturnpt.leftlateral(stomachindirectionofgravity)

7/17

Module8 2.2.2

NeurologicalSystem

Management
ABC Placept.leftlateral Assessvitalsigns o Keepaneyeopenforhypertensionandbradycardia o Maysuggestraisedintracranialpressure Administeroxygen(atleast60%) DONTrestrainthepatientduringconvulsion o removeANYobjectsaroundthept.thatmaycausefurtherdamage HGT o HGTresultwillbeverylow Callforbackup TransportNOsirens SuctioningmayberequiredBecarefulnottoinducevomiting GCS

2.2.3

AMS(AlteredMentalStatus)(RMBGCSbelow15/15)
Hypoglycaemia Hypoxeamia Intoxication Drugoverdose Unrecognizedheadinjury Braininfection o Encephalitis Bodytemperatureabnormalities o hypothermia/hyperthermia Braintumours Glandularabnormalities Poisoning

2.2.4

AssessinganAMS(AlteredMentalStatus)Pt.
UseGCStoclassifyseverity Considerunderlyingissues Monitorfordepressedrespirations Ensurebasicairwaymanoeuvresarefollowed Provideprompttransporttohospital o Continuemonitorpt.

2.2.5

Geriatricneeds
Brainshrinkswithage Alwaysconsiderunderlyingconditions ElderlyareathigherriskforCNSillnessesandinjuries

2.2.6

Paediatricneeds
ChildrencanhaveAMScausedby: o Stroke o Seizure o Otherbrainemergencies Treatsamewayasadult Seizuresoftenfebrile(causebyhyperthermia) Transporttohospital

8/17

Module8
Comparison: Usemnemonic:HABITSCHAP CausesSeizures Hemorrhagebrain Anoxiaembolism Brainabscess Infection(meningitis) Temperature(fever/hyperthermia) Sugar(hypoglycemia) CongenitalEpilepsy Headinjury Alcohol Poisons/Drugs

NeurologicalSystem

H A B I T S C H A P

CausesAMS Hypovoleamic Anoxia Braininjury,CVA Infection(meningitis) Temperature Sugar Convulsions Hypertension Alcohol Poisons/Drugs

3
3.1

HeadTraumaInjuries/Conditions
Headinjuries
Commonlycausebytrauma o E.g.MVA/assault ThesesituationparticularlyMVAneckshouldalwaysbeassumedtobeinjured(untilprovenotherwise) Headinjuriesmaybeclassifiedinto: o Scalpwounds o Skullfractures o Intracranialinjuries

3.1.1

Scalpwounds
Causedbysharpobjectcausingincised/penetratingwound/blunttraumacausinglacerations Thesewoundsbleedfreelyduetorichbloodsupplytoscalp Bleedingmorepersistentinelderlyarteriesareharderandlessabletoconstrictandstemtheflow Infantsbleedingmayresultinshockbecauseofsmalltotalbloodvolume

3.1.2

Skullfractures
Indicatessignificantforceofinjurytohead Skullfracturemaybeopen/loose/closed Thoughtfracturesmaynotbeclinicallyevidentmaybesuspectedif: o Pt.headappearstobedeformed o Cerebrospinalfluid(withorwithoutblood)comingoutofears,noseorboth o Raccooneyes(ecchymosisbruisingaroundtheeyes) o Battlesigns(ecchymosisbruisingbehindtheears) Someskullfracturesareobvious o Depressedfractures o Brainoozingfrominjuredarea Facialfracturesfrequentlyaccompanyskullfractures Maybelifethreateningwhenlooseteeth,bloodclots/fracturesjawcouldcauseblockedairway

3.1.3 Intracranialinjuries 3.1.3.1 Concussion

Pt.losesconsciousnessthenregainsconsciousnessandGCSimproves Forceofblowtoheadorfacetransmittedtobrainandcausestemporarylossofabilitytofunction o E.g.temporarylossofmemory(amnesia)/temporarylossofconsciousness

9/17

Module8 3.1.3.2 Contusion

NeurologicalSystem

Contusionmeanphysicalinjurytothebraintissue o Associatedwithbleedingandswelling MayresultindeterioratingLOC

3.1.3.3 Intracranialbleeding
Severeheadinjurycausinglacerationofbloodvesselsinsideoronsurfaceofbrain Resultinginhaematoma(bloodbleedinginaspecificarea)whichmaybe: o Extraduralepiduraloutsidethedura o Subduralbeneaththedura o Intracerebralwithinthebrainsubstance

3.1.4

Management
ABCusingjawthrust Oxygenmin60% History Insecondarysurveyobserve: o Pulse Usuallyslowbutbounding o BP Increaseduetoraisedintracranialpressure o Breathing Noisyduetoairwayobstructionblood/vomitus/teeth/Cheynestokes o Temperature Tendencytoincreaseotherfactorsmaypreventsthiscoldshockexposure o Skincolour Usuallynormaldependsonpresenceofshock o GCS Decreasedlevels Callforbackup TransportASAPandleftlateral

4
4.1

Associatedinjuries
Fractures Linearfractures
Hairlinefracture Linearfracturesarebenign(nonlethal)donotrequiretreatment Fracturelineusuallydisappears o 34yearsadults o 6monthsinchildren Ifanyneurologicalfeaturespresentmoresevereinjuryshouldbeexpected Linearfracturetooccipital/temporalbonecouldbeinvolvedinhaemorrhageduetoarteriessituatedcloseto bonesintheseareas

4.1.1

4.1.2

Depressedfractures
Resultshighvelocitycontactsustainedoversmallsurfacearea. Eitherclose,compound,complex o Closewhenscalpstillintact o Compoundwherescalpopenbutduramaterstillintact o Complexwherescalpandduramaterislaceratedbybonefragments Bonefragmentscanembedthemselvesintobraintissueandcausehaemorrhage

10/17

Module8 4.1.3

NeurologicalSystem

Signsandsymptoms
CSFfromnoseandears Blown,unequal/slowrespondingpupils Paralysis Vomiting Seizures Obviousskulldeformities

4.1.4

Complications
Infections Seizures

4.2

BasilarFractures(BaseofSkullFractures)
Locatedatthebaseoftheskull Mechanismofinjuryisusuallygreat Baseofskullfracturesnotnormallypickedupbynormalxray Clinicalfeaturesusedtomakediagnoses Baseofskullfracturecouldbeclassifiedas o Anteriorfossa o Middlefossa o Posteriorfossa Eachfossahasdifferentclinicalfeatures

4.2.1 Clinicalfeatures 4.2.1.1 AnteriorFossa

Rhinorrhoea o Nosefilledwithsignificantamountofmucousrunningnosemucous Epistaxis o NosebleedCFSorblood Periorbitalhaematoma o Racooneyes Battlesigns o Ecchymosisbehindtheearusuallyonlyafter24hours Haemotympanum o Bleedingfromtheears Death Spinalcordinvolvement PresenceofotorrheaandrhinorrhoeaisindicationofDurallacerationandincreaseriskonMeningitis

4.2.1.2 PosteriorFossa

4.2.2

Complications
Infection CranialNerveDamage

11/17

Module8 4.2.3 CushingsTriad

IncreaseBloodPressure Widepulsepressure+bounding

NeurologicalSystem

DecreasedPulseRate

ChangeinRespiratoryPattern Increase/ Decrease CheyneStokes

Risingbloodpressure Changeinrespiratorypattern Decreaseinpulserate o Cushingstriadshouldberecognizedtobeclearbutlatesignofrisingintracranialpressure Headinjuries Increased Decreased Decreased Shock Decreased Increased Increased

Vitalsigns Bloodpressure Respirations Pulse

4.3

FacialInjuries

Maxillofacialinjuries Componentsthatcanbeaffected: Arteries Nerves 5thcranialnerve(trigeminal) 7thcranialnerve(facial) Frontalbone Nasalbones Maxilla Zygomaticbone Mandible MajorcausesofmaxillofacialtraumaFrommosttoleastfrequent o MVA o Homeaccidents o Athleticaccidents o Animalbites o Intentionalviolentacts o Industrialinjuries Maxillofacialtraumamaybeclassifiedas: o Softtissueinjuries o Facialfractures

12/17

Module8 4.3.1

NeurologicalSystem

Softtissueinjuries
Softtissueinjuriestothefaceoftenappearserious Damagetothetissueofmaxillofacialareaisseldomlifethreatening Exceptforcompromisedairwayduetopotentialforsignificantbleeding

4.3.2

History

Obtainthoroughhistoryfrompt. HISTORYSAMPLE OPQRST

4.3.3

Management
ABC o Assessairwayforobstructions(bloodteeth) o Suctionifneeded o Secureandmaintainairway Usespinalprecaution(assumept.hasaspinalinjury) Oxygenmin60% o Ensureadequateventilations&oxygen Controlbleedthroughdirectpressureandpressurebandages

4.4

FacialFractures
Commonafterbluntforcetrauma Lookforsignsandsymptoms Fracturesofmandible Dislocationofmandible

4.4.1

Facturesofthemidface

Middlethirdofthefaceincludes: Maxilla Zygoma Flooroftheorbit Nose

13/17

Module8

NeurologicalSystem

4.4.2

FracturesofZygoma

Articulatesfromfrontal,maxillary,temporalbones Frequentlyassociatedwithorbitalfracturesandmanifestsimilarsigns

4.4.3

FracturesofOrbit
Blowoutfracturestoorbit Injurytoorbitalcontentsiscommon Shouldbesuspectedwithfacialfractures

4.4.3.1 Signsandsymptoms

4.4.4

FracturesoftheNose

NasalbonefracturesmostfrequentofALLfacialbonefractures Nasalinjuriesmay Depressdorsumofnose Displacenosetooneside Resultonlyinepistaxisandswelling(withoutskeletaldeformity) Orbitalfracturesmayalsobepresent

4.4.4.1 Management
ABC o Assessairwayforobstructions(bloodteeth) o Suctionifneeded o Secureandmaintainairway Usespinalprecaution(assumept.hasaspinalinjury) Oxygenmin60% o Ensureadequateventilations&oxygen Controlbleedthroughdirectpressureandpressurebandages Controlepistaxisbyexternaldirectpressure

4.5

Nasalandearforeignbodies
Insertionofforeignbodiesinnoseoreariscommoninchildren o Mayneedtobetransportedforphysicianevaluation Foreignbodyinearshouldberemovedifitcanbeeasilyretrieved Asarule: o ForeignbodiesshouldNOTberemovedinprehospitalsettingunlessit: o Contributingtoairwaycompromise o Canbeeasilyremovedwithoutequipment

14/17

Module8 4.6

NeurologicalSystem

EarTrauma
Lacerationandcontusions o Usuallyresultfrombruntforcetrauma o Usuallytreatedbydirectpressure(tocontrolbleeding) o Andapplicationofice/coldcompressiontodecreaseswelling Avulsedtissueshouldberetrievedispossible o Wrapinmoistgauze o Sealinplastic o Placeonice o Transportpt.andavulsedtissueforsurgicalrepair

4.6.1

Causesofeartrauma
Thermalinjury Chemicalinjury Traumaticinjury o Impaledobjects Barotitis

4.7

EyeTrauma

Commoncausesofeyeinjury: FromMVA o Bluntforcetrauma o Penetratingtrauma Violentaltercations Chemicalexposure(household/industrialaccidents) Foreignbodies Animalbites/scratches Evaluation Avulsion

4.7.1

SpecificEyetrauma

Allvictims/pt.of/withoculartraumashouldbeevaluatedbyphysician Foreignbodies Cornealabrasion Bluntforcetrauma Penetratinginjury Protrudingintraocularforeignbodies Chemicalinjuriestotheeye

4.8

Contactlenses
Hardlenses Softhydrophiliclenses Rigidgaspermeablelenses Asarule o EMSpersonalshouldNOTattempttoremovecontactlensesinpatientswitheyeinjuries

15/17

Module8 4.9

NeurologicalSystem

Dentalteeth
32teethinadultsmouth Eachconsistsoftwosections o Crown o Root Hardtissueofteeth Softtissueofteeth Toothfracture Toothavulsion

4.10 AnteriorNeckTrauma
Causebybluntforcetrauma/penetratingtrauma Mayresultin: o DamagetoSkeletalstructure o Damagetovascularstructure o DamagetoNerves,muscles,glandsofneck

4.10.1 CommonMechanismsofinjury
MVA Sportandrecreationalactivities Industrialaccidents Violentaltercations Hangings

4.11 Lacerationsandpuncturewounds
Superficialinjuries o Canusuallybemanagedbycoveringwoundtopreventfurthercontamination Deeppenetratingwounds o Associatedmorewithseriousinjuriestounderlyingstructuresandmayrequire: Aggressiveairwaytherapyandventilationsupport Suctions Haemorrhagecontrolbydirectpressure Fluidreplacement

4.11.1 SignsandSymptomsofsignificantpenetratingnecktrauma
Shock Activebleeding Tendernesstopalpation Mobilityandcrepitus Large/expandinghaematoma Pulsedeficit Neurologicaldeficit Dyspnea Hoarseness Stridor Subcutaneousemphysema Haemoptysis Dysphagia Hematemesis

4.12 VascularInjuries
Bloodvesselsmostcommonlyinjuredstructuresinneck o Maybebybluntforcetrauma o Penetratingtrauma Vesselsatriskofinjuryinclude:

16/17

Module8
Carotid Vertebral Subclaviculararteries Internalmammaryarteries Jugularandsubclavicularveins

NeurologicalSystem

4.12.1 Management
ABC o Assessairwayforobstructions(bloodteeth) o Suctionifneeded o Secureandmaintainairway Usespinalprecaution(assumept.hasaspinalinjury) Oxygenmin60% o Ensureadequateventilations&oxygen Controlvascularhaemorrhagingbyconstantanddirectpressureandpressurebandages

4.13 Laryngealandtrachealinjury
Injuryissecondarytobluntforcetrauma/penetratingtraumatoanteriorneckmaycause: o Fractureordislocationoflaryngealortrachealcartilages o Haemorrhaging o Swellingofairpassages Rapidandjudiciouscontrolofairwaycansavelivesofmanypt.withthisinjury o MaintainHIGHdegreeofsuspicionfor Associatedvasculardisruptions Oesophageal Chest Abdominalinjury Emergencyairwaymanagementintheseinjuriesiscontroversial

4.14 Oesophagealinjuries
Shouldbesuspectedinpt.withtraumatoneckorchest Specificthatrequirehighdegreeofsuspicionforassociatedoesophagealinjuries: o Trachealfractures o Penetratingtrauma(fromstaborgunshot) o Ingestionofcaustic(e.g.acid)substance

4.14.1 SignsandSymptoms
Subcutaneousemphysema Neckhaematoma Oropharyngeal/nasogastricblood o Indicatingoesophagealperforation

17/17